Robotic Right Hemicolectomy for Tubulovillous Adenoma with High-Grade Dysplasia: Multimedia Analysis of a Contemporary Technique

CHAPTER 1

In general, you want to - try to avoid midline extraction. That's the highest hernia rate. So a lot of times I'll do Pfannenstiel on the left colons. On the right colons I'll usually just use the stapling trocars as the extraction site, which is off midline. Probably has the lowest hernia rate. Probably slightly lower than the - Pfannenstiel, even. So Optiview trocar allows us to - see the layers as we're inserting. It's slightly suboptimal because it's a 30° scope, but - still enough to see what we need to. Always want to leave the obturator in because otherwise it's a direct channel in and all the insufflation will come out. Hit the air seal button. It creates a continuous flow circuit so it's suctioning and insufflating continuously. Maintains the pneumo at a more steady pace, so if you put the suction irrigator in and just put it on full suction, it'll still maintain the whole field of view. It also provides continuous smoke evacuation. And this is just - basically makes it a little bit quieter. Can we have the room lights down?

I always like to look where the - Veress was, make sure there's no - injury to anything in the left upper quadrant. Now because this is - even though the initial biopsies are benign, just like it was a malignant case, we'll look at the bilateral lobes of the liver to make sure there's nothing suspicious for malignant spread. And the same thing for the peritoneal lining. Which, other than the Veress site, looks pretty normal. Knife.

Eight.

All right, I'm going to move this over to here. And start with the far one and work this direction. Your assistant. And that's going to be an 8. So it's going to be 8, 8, 12.

So in some cases, for certain lesions you would want to inspect the peritoneal cavity to look for a tattoo. In this case we know endoscopically they identified it as being at the ileocecal valve specifically, but if it's anything where they didn't directly visualize the anatomy, it's at the hepatic - they say it's at the hepatic flexure or splenic flexure or transverse or - And it's something they've tattooed. A lot of times you want to verify the location before you put your trocars in. Otherwise you might not be set up for the correct operation. Here with the Xi, since it's a linear port placement - that is - less of an issue because it gives us a little flexibility for left colectomies or right, either one from the same trocar placement.

So we're trying to expose the medial aspect of the right colon mesentery. Sometimes the omentum's in the way. Can we do a little bit less RT? So we had to make a decision about what approach we're going to do, lateral-to-medial versus medial-to-lateral. It's determined by your ability to expose this - ileocolic pedicle, which in this particular case is a little bit difficult because he's - got a little bit of retroperitoneal fat. It may be easier once I have an extra arm to retract that way. Okay. That'll work. All right, Brian. Let's dock.

CHAPTER 2

We got a target. You got a target first? Okay.

[Robot speaking] Point the scope at the target anatomy, then press and hold the targeting button.

Just ask the da Vinci reps, they'll tell you. They'll tell you how smart the robot is.

[Robot speaking] Targeting complete.

If you ever look, the alignment is roughly...

[Robot speaking] Now for the remaining arm.

The trajectory of the trocars. So if you ever need to - in a situation where you can't target it for some reason - that's generally - a general way to do it without - actually doing the targeting. Just to make sure that it's sort of in alignment. Tip-Up and a scissor. Tip-Up.

Fenestrated bipolar.

Sometimes you have to push this back for a minute while we visualize these two. So just follow that. Now you can swing that trocar back around. Yes. A little bit. Looks good.

CHAPTER 3

So the intent here is to try to do medial-to-lateral because it - probably 85% of the colectomies in the US lap minimally invasive are done medial-to-lateral. The reason is...

Why is it? Is it just because it's easier, or...?

Yeah, because when you work lateral-to-medial in a confined space, it is - then you're always pulling the anatomy towards the camera. You can do it that way, and sometimes, and even in this case we may find that we have to - But it allows you to, number one, gain early vascular control and work away from the camera.

What we're trying to do is identify the ileocecal junction, which is - probably here. You can see the terminal ileum. Veil of Treves. Once you find the ileocecal junction, then that's where you want to hold the colon and retract All this fat is kind of stuck here funny.

Yeah, that I'm trying to hold on to. And he's got a lot of mesenteric fat, which is making it a little bit challenging. And so I keep looking back.

I sort of - I was trying to pull the - cecum forward a little bit. That's the ileum right there. So you usually want to grab this fat pad and lift up, and it's usually this - it's going to be this column right here. Now this is not exposing quite as nicely as I would expect. I think it's just because he has a lot of fat. But see how this tents up right here? All right, can you come in through the assistant port with a Dorsey grasper? All right, try to grab this wad of fat. Yeah, now lift - up and away - Let go for a second. Go lower. Right there. Good. Now lift it up towards the abdominal wall - that's good. And - okay. If I start hitting you, tell me. Because I'm - it might start - I'll try to come under you. So that's going to lift this column of tissue here. And we have to be cautious, the things you can injure in this area are usually the - duodenum.

Right there.

The answer is not Roanoke.

And it's different than this purplish thing right here. Yeah. So once we've incised the peritoneum where the ileocolic pedicle should be, we want to - that vessel that we're seeing is probably the ileocolic vein. And then this other purple stuff down here is the duodenum. We don't want to operate on the duodenum today, so you'll see me pushing on it. This is just to bluntly push the duodenum down See, as I lift up on the mesentery, it tends to pull the duodenum up, so I'm trying to keep this out of our way. The head of the pancreas will be out this direction.

What I'm doing now is just - now that the duodenum is out of our way, it's way down here, and I've lifted those vessels up into the air. And you want to get around the vessels. And I'm actually going to skeletonize these a little bit, since we're using a vessel sealer. If you go straight through the fat with a vessel sealer and try to seal them, you may not seal the vessel completely, so - Going to get some of this tissue out from around it.

There's a fair number of small collateral vessels and lymphatics that can cause some oozing through here.

Once this is skeletonized, then you can come across the pedicle. Now, you'll notice as I get ready to seal this pedicle that with my left hand - I'm lowering my left hand to decrease the tension that I'm holding the vessel. This is so it doesn't rip the vessel as I'm sealing it with the energy device. If so, it'll just avulse and you'll get a lot of bleeding. And then I'll move distally. You can see some atheroma from the vessel coming out.

And then I divide it from above. It starts to retract down, so you can imagine if this avulses and it's bleeding and it retracts down into the retroperitoneum, usually - Yeah. This is bleeding a little bit from this back side so I'm trying to pull the vessel up with my left hand a little bit, just seal this edge of it. Another advantage of the robotic instrument is having two separate bipolar devices running at the same time.

So, once you have that then the distal end of the ileocolic pedicle is all in this tissue.

So once we've taken the pedicle, we go back to the same plane, again - keeping the duodenum down. And we're going to push the retroperitoneum down as well, so that's this plane right here. So this is getting the retroperitoneal fat down. As you do this, you have to continually work the left hand deeper to provide more counter-traction so that you continue pushing this down. And you're going to work underneath the transverse and right colon until you get to the lateral peritoneal reflection. So again, duodenum, sweeping it down gently. And then eventually - you can see I've broke through here And you can see the liver on the other side, so - this is - what's left of sort of hepatocolic ligament.

Correct. So everything down here is going to be retroperitoneal fat, Gerota's fascia. The kidney's going to live back there. And you can see this guy - this particular patient has a large amount of that fat. And eventually we'll be able to see the gallbladder.

I'm going to try to move my left hand up closer to this direction, because I want - to really make sure the duodenum is down. The reason is, as you go to make your anastomosis, you don't want anything tugging on the duodenum, putting it under tension.

And that's probably going to be enough. Because that's - then we're - almost to midline, if you really look at where we're dividing back here. We're going up into the gallbladder fossa area. That's pretty good distal. Now the other thing I can do is take this hand, which was retracting there now, and bring this underneath to help hold that up, and that's going to - allow me to change where I'm holding tension with my left hand. Again, moving the pedicle tissue out to the - side.

This is, again, not the - way that you see the anatomy in an open case, so it can be disorienting. So I'm - turning the corner to come down the lateral peritoneal - the right lateral peritoneal reflection from inside. Or you can flip this down here in a minute, we can flip it down and take it from the lateral side.

Sometimes this - retroperitoneal fat is really bulging up. So at this point it may be easier to - drop the colon. You're not holding anything, correct?

Large cecum.

Hey, we'll use the 60 stapler.

The more you mobilize, the floppier it gets. The harder it is to see. There's our pedicle. Shouldn't be anything caught underneath there now. All this small bowel's in the way. Yeah. We'll use blue loads. Yeah.

Do you have that grasper for a second?

Can you grab that appendix and take it over here to the right? That's good, stop.

Okay, drop it. All right.

Connect the dots.

That's our pedicle.

Now we're just going to divide the mesentery to the ileum. A few little attachments left.

Stapler in 3.

CHAPTER 4

It's a big stapler, it's a 60, so...

Now this stapler, when you, um - it works differently than the 45. I don't know if you did any Salzburg's cases with this stapler. So sometimes it may stop in the middle of firing to regrasp and to compress more. It shouldn't on this case, because the ileum and the - the in the right colon are thin-walled. Sometimes in the left colon it'll do that. You just keep your foot on the pedal. So you want to go somewhere in here.

And you can use the stapler kind of as a grasper to hold the ileum until you can readjust with your left hand and get a better bite you You want to try to get it all the way back into the jaw here so that you have nice clearance on the tips and you can see that the tips are not going to injure something else, but also so that you don't have to use more than one staple load. I think that looks good.

Okay, open the jaw. It seems to have stapled all the way across. Stapler out.

All right Caleb, you should be able to staple across this. When you do, I want you to pull this tenia into the jaw at the corner. Okay?

And again, you want to try to tip the jaw up - yeah. Ideally we want to get across in one firing if we can.

Yeah, it's a little wide right there, so it may not be possible.

Can you - is it possible to open the jaw and angle the wrist slightly back this direction more? No? Is that as good as it gets? Yeah, okay. That's fine. Yeah, just take what you have, and if we have to fire again, that'll be fine.

Open the jaw.

Yeah, probably one more.

CHAPTER 5

Now this should be completely amputated at this point after your proximal and distal. Sometimes you might get a small area of continued connection, but it doesn't look like it. I'm going to shove this all towards the left upper quadrant and we'll take it out at the end. That's all - gone. So here's what's left of our transverse. And it's fairly mobile. It comes down very easily. And then our terminal ileum should be sitting right here with it, and it is. So we just have to put A to B.

7.5 mg.

Can I have a scissors in 3?

All right, take this needle out. This white part of the fenestrated bipolar glows and so you can use that as a positive control if you think the laser isn't working or something.

So I'm not very happy with this corner right here. This fat's not really lighting up either.

Can I have a - I'm going to need another staple load. It's going to be at least 2 loads, so you can open 2. If you don't have 1.

But I like the - I mean, this is a great thing with having - fluorescence, angiography capability, is being able to check these little corners and things.

Now the biggest thing is not losing this little nub of tissue. No - I bet I'll lose it up there. I'm going to put it right there.

CHAPTER 6

Make a colotomy here along the - tenia. Make an enterotomy somewhere here. You want to - you don't want to be right at the tip. Because you want to have room to suture this closed, so you got to come up here somewhere. A couple centimeters - 1 cm to 2 cm. And you want to be on this antimesenteric side. Correct. So something here, something there. And then we'll put the stapler in and fire it.

Yeah, somewhere - maybe even up here. Now, I use a little bit of cautery to make these openings. Otherwise they bleed.

Yeah, I think you're in.

It looks like it's in. That looks like mucosa, right?

Yep. And put the other pair - put the other leg of the pants on.

Yeah, you want to close the jaw slightly. There you go. Not all the way, just slightly. And that way it slides easy. That looks pretty decent. That side. Good, yeah. Great. And you just kind of lift up slightly on it, you're already doing that, but go ahead - that's good. Just clamp there.

As you take the stapler out, you kind of want to try to look into the anastomosis a little bit to see if you see any massive bleeding or anything.

That looks pretty good, no bleeding.

Now we can probably - at this point you can let go of the stay suture with your extra arm.

So you want to use that to pull this fat back this way a little bit. Because we want to be able to see this anastomosis very clearly. That's good. Just hold it right like that. Now, see, this staple line is going this way, the other one underneath.

This way a little bit, so you can see - So this staple line goes this way. The other staple line posteriorly is back here. This is the most common place to miss when you're closing this, okay, so - this posterior side right back here, so it's really - we have to really make sure we get - you know, across the whole thing.

So, you can either go - start at this staple as the apex and put this as the other corner, or you can close it this way. So, either direction. Yeah, that's fine. And so my technique is to - I try to use the same suture and I do full-thickness bites down one direction and then running Lembert back the other direction with the same suture. Sometimes you run out of suture because this one's - it's only a 9 inch suture, so... With this one - this one has a loop on the end, so you just take a bite and then you have to run it through the little loop on the end.

You can leave the knot if you need to.

CHAPTER 7

All right, now relax that other arm and bring the omentum and pile it across the anastomosis. So that we don't see it anymore.

Looks great. Do you have that needle driver?

Like that. It's going to go with the final specimen. We'll just throw it in the bucket with it. Go find the specimen. It's up in the left upper quadrant somewhere. And I want the TI portion. That's the pedicle. There's a staple line. That's the colon's end. That'll work. Just give me that end. All right. That's good. Now just... All right. Let's undock.

CHAPTER 8